This is a sample of the form for review only, the current form will be given to each student for the parent or guardian to sign.

Student Permission Form for Gatherings Field Activities

American Diversity Report-New Beginnings; 39B Mill Plain Road, Suite 2; Danbury, CT 06810  Website: adr-nb.org

The American Diversity Report-New Beginnings (ADR-NB) branch location requires that written permission by the students/child’s parent or guardian be given for them to participate in the activity described below.  This permission slip must be completed and signed in order for your child to participate.  I understand that in the event of an unforeseen circumstance, ADR-NB reserves the right to cancel this activity without notice.  It is agreed that ADR-NB cannot be held responsible for any costs associated with the cancellation of the activity.  Some activities may involve visits to parklands, farms, farmer markets, orchards and food processing factories, bakeries, or restaurants.  If your child has any allergies or medical problems, such as hay fever or asthma, please be sure to list these below and advise the Program Manager or Team Leader as to any medication that might be needed.

Branch Name: ____________________

Branch Location: __________________

Name of Activity: ______________________________________

Brief description: __________________________________________________________________________

                                 __________________________________________________________________________

General Location: ________________

Expected Activity Dates: Starting ___________________ and Ending _______________

Departure Location and Time: _____________________________

Return Location and Time: ________________________________

Consider these Things to Take: ________________________________________

• Weather related items: _________________________________
• Snack or Drink: ­­­­­­­­­­­­­­­­­­­­­________________________________________
• Spending Money: _____________________
• Footwear if Hiking or Extensive Walking _______________________________

Program Manager: Name: ______________________________

                Email address: _________________________________

                Mobile Phone number: _________________

Name of Team Leader: _________________________________

                Email address: _________________________________

                Mobile Phone number: ____________________

Students Name: ______________________________

                Email address: ________________

                Mobile Phone number: _________________

Please Supply two Emergency Contacts:

Emergency Contact1: Name, relationship, and Phone Number: _____________________________ 

Emergency Contact2: Name, relationship, and Phone Number: _____________________________

My child has the following medical conditions that might interfere with his/her participation on this activity:

• Allergies: _______________________
• Special Medications they will have with them:  _______________________

I certify that I am the parent or guardian of the above-named student/child that will be participating in the Gatherings Activity listed herein, and that ADR-NB has my full permission to attend the activity.  I understand there may be travel involved, which may be provided either by public conveyance and/or the use of a personal vehicle, driven by a team member, supervisor, or chaperone.  I hereby covenant and agree to release and hold harmless ADR-NB, it’s employees, and participating members, from and against any and all liability, loss, damages, claims or actions (including costs and attorney fees) that may arise because of my child’s participation in this activity.  In the event my child needs emergency or medical treatment, ADR-NB will attempt to contact us, the parent/guardian.  In the event I/we cannot be contacted, I give my permission, as evidenced by my signature below for the Team Members and supervisors to secure prompt treatment.

Please Print: Parent/Guardian Name: __________________________________

Parent/Guardian Signature: _________________________________   Date: ___________________

Phone Number: ___________________________

Email Address: ____________________________